Monday, February 1, 2010

Quiz Time

Take out your pencils and put away your books and let’s take a quiz Dr. Grumpy style.

QuestionYou are a registered nurse employed at a nursing home. During lunch time, you notice that one of the elderly residents is making a strange hacking noise and appears to have progressive difficulty breathing. This particular resident has a history of dysphagia (difficulty swallowing), chronic obstructive lung disease and is easily distracted by external stimuli (such as other residents eating). Do you;

a) Check the mouth for possible sources of obstruction (such as food) and attempt to clear it.b) Ignore your (much junior) colleague’s about checking the mouth of possible sources of obstruction.c) Chide her for not finishing her meald) Panic, call EMS and have her transported to the local ED and repeatedly express your concerns over the patient’s falling oxygen levels as something beyond her baseline. Also emphasize concern about her recent diagnosis of a UTI.e) Call her family and tell them that perhaps now is the time to see grandma and they better hurry.f) b & dg) b, d & e

If you chose answer g, you are correct. Bonus points if you were able to elaborate as to why EMS didn’t sense that something was amiss either.

Key learning summary: Some days, the only course of action at one’s disposal is to let head meet desk. Repeatedly.

When the circumstances are hazy, I call the nursing home and talk to whoever made the decision to send a patient. Still doesn't get me far in my questions, but at least I can say I tried! Good post, well done.

1. Foley catheter needs to be changed (Um...aren't you RN's? Why can't you do this?)

2. G-tube is broken. Which, for some reason, gets sent in at 0300hrs. A few years ago, we used to admit these to hospital, to have the tube replaced in the a.m. Now, our ED has collectively decided for these problems that we put a foley cath. in place of the g-tube for the interim, and send them back to the facility with instructions to syringe the feeds through the foley, and MAKE AN APPOINTMENT to have the g-tube replaced at a better time.

We really should start billing the facility for these bogus ED visits, instead of MSP.

This post was funny but it also made me sad. Nursing homes are the bald headed stepchildren in the industry.Salaries are atrocious so you get what you pay for and are probably scaping the bottom of the barrel for staff. But families couldn't afford nursing homes if they paid their staff well and attracted competent people.I don't know what the answer is.

So what was the EMS side of this story?I once had a patient with fulminating CHF, I could hear it from the ER as the EMT's opened the bus doors out in the garage. They thought the patient had a sinus infection! Similar story from the NH, they had no idea of the patients heart hx.Steve

The nursing homes here just send them with no information. Without exception the patients are either just fine or near death. When we call for some history (why did you send them, or how long have you been ignoring this) the response is always, "I don't know I just started my shift."

Sometimes I think trained sheepdogs would be better at assessing the elderly for medical problems.

Midwest woman - I agree that nursing home staff are expected to put up with a whole lot with not a lot, but my point is that if another RN has the same license as me, s/he is obviously trained in BLS and just observing the patient and doing a finger sweep of the mouth doesn't require fancy equipment. High school kids know this when they take first aid courses. I felt that this particular case was such an obvious dump.

And I have no idea what the EMS side of the story is. Perhaps their shift was ending and they were in a hurry to get rid of this patient?

Alternately the EMTs may have been given an AWFUL dispatch and/or told "the patient is altered from a UTI" or "this is the patient's baseline", in which case they probably rolled their eyes, said "aw dammit, another nursing home dump to the ER" and just carted her in, never THINKING to check the airway.

About Me

Obvious Disclaimer

I like my job. I do not want to lose it for violating patient confidentiality. I have a fairly active imagination so altering identifying details is something I enjoy. Everything here is altered to protect patient confidentiality. If you think that a story is referring to you, it’s not. If you think a picture is from your medical exam, it’s not.